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Investigation and recommendations from an expert group on drug treatment and interventions for people in prison in England calls for a clear focus on recovery and for the commissioning and coordination measures needed to improve outcomes without extra resources.

Summary The Prison Drug Treatment Strategy Review Group (henceforth known as the Review Group), chaired by Professor Lord Patel of Bradford OBE, is an independent expert group commissioned to take a fresh look at drug treatment in prisons.

The review commenced in April 2009 and the Review Group's remit was to focus on drug treatment and interventions for people in prison in England, people moving between prisons and the continuity of care for people on release from prison. The review focuses on adults (18 years old plus).

This report outlines the evidence gathered and work carried out by the Review Group and summarises their conclusions and recommendations. These recommendations have been sent to Ministers in the Ministry of Justice, Department of Health and the Home Office, and have been submitted as a response to the new drug strategy consultation.

The need for reform

Existing drug treatment funding, commissioning and delivery systems in prisons have been subject to increasing criticism. While the current systems have helped to deliver an increase in drug treatment in prisons, they are complex and characterised by a multitude of funding streams, commissioning and process targets. This has resulted in a fragmented system with the risk of a 'one-size-fits-all' approach, with limited choices in the type of treatment and broader social support available.
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The Price Waterhouse Coopers (PWC) report specifically identified:
• The lack of a clear, unified inter-departmental strategy across Government;
• Fragmented organisational arrangements for funding, commissioning,
performance management and delivery of services in prisons;
• The lack of a clear evidence-base for some services currently offered in prisons; and,
• Inefficiencies and gaps in services.

The criminal justice system presents an opportunity and a challenge when addressing a wide range of clinical and social care needs of drug users. We know that getting drug users in prison to engage in treatment can have a positive impact.

We recognise that the continuity of care of drug treatment for people entering prisons, moving between prisons and on release is a complicated issue due to the nature of the prison environment – a rising prison population resulting in a strain on limited staffing resources, disrupted regimes and some prisoners being placed further from home.

However, there is now a strong call amongst drug users and carers for greater continuity of drug treatment both within and between prisons. And there is a very clearly articulated need for much greater support and help on release especially with respect to appropriate housing, having enough money, having something meaningful to do and greater integration and co-ordination with community services.

We have been concerned that the progress required to make the kind of system changes necessary to address the criticisms raised has been slow. However, since the inception of this review, there has been a substantial change in the political landscape. The Coalition's programme has indicated a keenness to re-look at issues with regard to drug use, crime and rehabilitation and the NHS White Paper, Equity and excellence: Liberating the NHS, has already announced fundamental changes to the commissioning system.

With further changes likely to be announced within the new drug strategy, the Ministry of Justice Green Paper, 'Engaging Communities in Criminal Justice', etc. we now have an opportunity to achieve the cultural and system change needed to engage drug users and the communities within which they reside in effective drug treatment while in prison, and to maximise their prospects for recovery and reintegration on release into the community.

Our recommendations are intended to be in step with this changing political landscape, eg, streamlined commissioning systems and a move towards outcomes. We seek to raise the levels of ambition about what can be achieved and to challenge the reluctance to recognise and harness the full potential of drug users to actively engage with and assume responsibility for their own recovery, including a renewed focus on abstinence as a clear goal.

Economic constraints

There can be no doubt that developing effective drug treatment and interventions in prisons and continuity of care on release in the context of tightening resources will be demanding – drug users' priorities may become low ranking in a difficult economic climate.

Within a tight fiscal context, local partnerships, commissioners and prison governors will have to make tough choices about where to target investment for the future and have a determination to get value for money from every pound spent by increasing innovation, raising standards and quality, achieving efficiencies and improving cost effectiveness.

Equally, economic constraints can have the potential to be catalysts for change. Improvements can come from making changes in current practice and refocusing efforts and resources, including better working practices in terms of commissioning and delivery to allow the frontline more capacity to innovate.

Therefore, we have worked on the basis that our recommendations should not need additional money to implement them, but would need to address:
• Improving the quality of drug treatment for people in prison and on release from prison, through the development of clear standards and outcomes.
• Increasing innovation – in terms of service delivery, commissioning and partnership working – to contribute to a reduction in re-offending and reduced mortality from accidental drugs overdose or chronic health problems such as blood borne viruses.
• Achieving efficiencies and improving cost effectiveness within the drug treatment system in prison and for people on release from prison.

Achieving the above will require genuine collaboration cross-Government and coordinated commissioning between local prisons and their community partners if effective drug treatment and interventions in prisons and continuity of care on release is to be established as a fundamental part of the work of the whole prison establishment and an integral part of local commissioning partnerships.

Review Group approach and key principles

Our review and recommendations have been strengthened by a thorough review of the evidence base for drug treatment in prisons incorporating over 160 high quality peer reviewed papers, and a service user and carer consultation based on 553 responses.

Our aim is not to 'reinvent the wheel' but to build on the successes of preceding strategies, research and reviews. Accordingly, we have taken into consideration a wide range of key work programmes and reviews, including the Bradley Report, the Drug Interventions Programme review and the National Offender Management Service (NOMS) review of accredited substance misuse interventions. Research on efficiency savings and value for money on drug treatment in the community and in prisons was also considered.

We believe that the goal of all treatment is for drug users to achieve abstinence from their drug – or drugs – of dependency. For some this can be achieved immediately, but others will need a period of drug-assisted treatment with prescribed medication first so their overall health can be improved, which will enable them to work, participate in training or support their families. They can then be supported in trying to achieve abstinence.

We believe that an integrated care pathway, from the community into prisons and vice versa, and a balanced treatment system are vital to ensure that individuals get access to the types of treatment that is appropriate to their changing needs and circumstances. Local commissioners need to be able to choose from a broad spectrum of treatment options in both prisons and the community including prescribing and residential rehabilitation.

Treatment alone can only go so far and we need to be more ambitious in helping drug users to make lasting changes, to maintain their recovery and ensure that there is help and support from outside the treatment system – family and friends, peer support/mutual aid networks, access to housing, and education and employment opportunities.

Hence, our work during this review has been underpinned by the following key principles:
• Continuity of care as people pass through, in and out of the prison system is the critical issue.
• Drug users in prison should have access to drug treatment and health and social care provision equivalent to those provided in the community and appropriate to a prison environment.
• Drug users released from prison should be offered on-going rehabilitation and support on their return to the community and be encouraged to maintain their contact with community substance misuse services, as appropriate.
• Existing finite resources should be used more effectively.
• The range of services provided should be appropriate, supported by best available evidence and ensure an equivalence of national standards of care across the country.
• The needs of particular groups, eg, transitional issues of the 18–21-year-old prison population, women, black and minority ethnic groups, people with dual diagnosis (mental health and substance use problems) must be considered.
• It is vital that the service users 'voice' is heard and their experiences are taken into account.

Key issues for change

We believe an effective and balanced drug treatment and interventions system would contribute to a range of criminal justice and health outcomes, including:
• Reducing drug related offending and re-offending;
• Reducing drug use in prison;
• Community safety;
• Individual drug user's health and social functioning;
• Lower public health risks from blood borne viruses and overdose.

In developing our recommendations, there was a wide range of issues that this review could potentially focus on. However, to attempt to tackle all issues could result in a diluted approach that fails to have any impact at all.

Therefore, we have chosen to focus on challenging and making improvements in the key areas outlined below. We believe making changes in these areas would have the most significant impact and deliver improvements in the outcomes and experiences of drug users in prison and on release:
• More decentralisation around commissioning enabling a more autonomous and accountable system: Decision-making should be focused at a local level, and more responsibility given to local partnerships, commissioners, prison governors and users and carers. Maximising local ownership will sustain and improve outcomes in terms of both re-offending and reduction of harm to the individual, their families and their communities. Local areas require greater autonomy and flexibility to deliver better services by focusing on increasing the access and quality of drug interventions, matched to individual needs, and on reducing bureaucracy.
• Clear outcomes to improve efficiency and effectiveness of commissioning: The development of an outcomes framework for assessing and managing performance at a local level, which is focused on recovery, is crucial. This will ensure that the services that are commissioned are needs based; delivered to high standards and achieve best value for money; and, realise any efficiency savings by removing duplication and reinvesting in improvements to services.
• Needs-based treatment and interventions: It is vital that drug treatment and interventions are matched to individual need and appropriate to individuals at the time that they are within the criminal justice system, ie, making sure that the right people, get the right intervention, at the right time. All available evidence must be used to make sure we are creating an integrated care pathway between prisons and community services that supports the treatment and interventions that are most effective, targeted at the right users with abstinence-based treatment for some, drug-replacement over time for others.
• Improving access to reintegration pathways and provision: Integrated care pathways can help to ensure that there is a focus on reintegration and appropriate support services at an early a stage as possible, to begin to address the broad range of issues around recovery and reintegration presented by people with drug problems in prison and on release.
• Integrated partnership working: To create an integrated care pathway and integrated services by improving partnership working between criminal justice, health and social care organisations, enabling effective health, social care and criminal justice outcomes.
• Improving capacity and capability: To have an informed and effective workforce to deliver services for drug users in prison with health and social care needs, making sure that they are able to work confidently across organisational boundaries, by equipping them with the right skills and knowledge to share information and take co-ordinated action that supports the continuity of care.
• Diversity and equity of access to services: Encourage the development of skills, awareness and knowledge in relation to issues of diversity with respect to drug use. This would include those relating to diversity of the workforce in prison and probation so that they can deliver quality drug services to the full diverse range of the population being served and firmly embed this into the working culture of the criminal justice system. This is vital to ensure that all offenders – irrespective of race, gender, disability, age, sexual orientation, religion or belief – will secure the same access to health and social care services, appropriate to their needs and in line with standards set for the rest of the population.
• Breaking barriers: Government departments need to work closely with external organisations and partners to ensure joined up national thinking across institutional boundaries; to help break down any barriers to local partnership working; establish shared objectives; and facilitate integrated care pathways between local agencies. This cross-boundary work should also continuously consider improvements in value for money.

It is important to note that all our recommendations are interlinked and so need to be viewed in an integrated way. For example, the commissioning and outcomes recommendations are complementary and both are necessary – without clear outcomes, effective commissioning standards cannot be established and the commissioning of effective care pathways covering drug treatment and interventions, continuity of care provision and mainstream reintegration/recovery services (housing, employment) are essential in helping drug users to make lasting changes.